Multiple Coronary Artery Aneurysms Detected by Cardiac Magnetic Resonance Imaging

Abstract

A 46-year-old male with acute coronary syndrome and signs of anteroseptal myocardial infarction without ST elevation on ECG (NSTEMI) presented for admission to hospital. Troponin I was elevated to 4.15 µg/l. Treatment with isosorbide dinitrate was initiated and led to resolution of symptoms.No wall motion abnormalities, signs of inducible myocardial ischemia by adenosine stress first-pass or myocardial necrosis could be visualized by cardiac magnetic resonance imaging. An additionally performed magnetic resonance coronary angiography showed multiple aneurysms in the proximal and middle segments of the left anterior descending (LAD), left circumflex (LCX) and right coronary artery (RCA; see Figure 1). A 1.5-T (Intera, Philips Medical Systems, Best, The Netherlands) magnetic resonance system was therefore used with a navigator-based steady-state free-precession three-dimensional whole-heart SSFP sequence (TR 3.8 ms, TE 1.9 ms, voxel size 0.9 × 0.9 × 2.0 mm, fat suppression, T2prep echo time 50 ms, trigger delay individually optimized dependent on diastolic rest determined with a standard functional protocol). For reconstruction we used the Soapbubble Tool 5.0 for PRIDE4 (Philips Medical Systems). We thus diagnosed embolic myocardial infarction probably due to coronary thrombi.On coronary X-ray angiography these findings could be confirmed ( Figure 2). Furthermore, coronary thrombi or occluded peripheral coronary arteries could be excluded. 3 days after admission troponin I had decreased to 1.42 µg/l. A combined anticoagulation treatment with acetylsalicylic acid (100 mg/day) and phenprocoumon (target INR [International Normalized Ratio] range 2.0-3.0) was initiated. Furthermore, the medical treatment was extended with a β-blocker, an ACE inhibitor, and a statin. A magnetic resonance follow-up study was initiated 3 months after first diagnosis and showed no progression of the aneurysms.The proximal and middle segments of the coronary arteries are the most common sites where coronary aneurysms are found [1]. Atherosclerosis is the most prevalent cause for coronary aneurysms [1, 2], but these could also be due to congenital, mycotic, or systemic inflammatory disease such as Kawasaki syndrome [3]. Figure 1. Cardiac magnetic resonance coronary angiography without contrast agent enhancement showing aneurysms of the LAD (1), LCX (2), and RCA (3), respectively.Figure 2. Coronary X-ray angiography of the left coronary arteries with verification of the aneurysms of LAD (1) and LCX (2).